Skin Problems Unexpected weight Loss/Gain None Explain: None Endocrine: Self Family: Musculoskeletal: Self Family: Thyroid

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Eugenia Wilkerson
5 years ago
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Demographics Last Name: First Name: Initial: : Guarantor: Address: City: State: Zip: Home #: Work #: Cell #: Email: Communication Preferred: email phone mail Pharmacy of Choice: of Birth: Male Female

1 Demographics Last Name: First Name: Initial: : Guarantor: Address: City: State: Zip: Home #: Work #: Cell #: Communication Preferred: phone mail Pharmacy of Choice: of Birth: Male Female Ethnicity: Social Security #: Marital Status: Race: Occupation: Employer if applicable: Vision Insurance Co: Medical Insurance Co: Chief Complaint What is the main purpose of your visit today? Spectacle Rx Status: (Do you wear glasses?) Yes No If yes, how old is the RX: For what activities do you wear glasses: Contact Rx Status: (Do you wear contacts?) Yes No If yes, type: Review of Systems Allergy: Self Family: Hematological/Lymphatic: Allergies Anemia Drug Hypersensitivities Bleeding Problems Explain: Immunological: Self Family: Cardiovascular: Self Family: Sarcoid High Blood Pressure Lupus Vascular Disease HIV Heart Pain Herpes Simplex Cholesterol Herpes Zoster Constitutional: Integumentary: Fever Skin Problems Unexpected weight Loss/Gain Explain: Endocrine: Self Family: Musculoskeletal: Self Family: Thyroid Arthritis Diabetes Rheumatoid Gastrointestinal: Joint/Muscle Pain Diarrhea Neurological: Constipation Headaches Genitourinary: Migraines Prostate Seizures Kidney Psychological: Bladder Depression Ear Nose and Throat: Other Allergies/Hay Fever Respiratory: Self Family: Sinus Congestion Asthma Runny Nose Chronic Bronchitis Post-Nasal Drip Emphysema Chronic Cough Cancer: Self Family: Dry Throat/Mouth

2 Medical History List all Medical Conditions or Hospitalizations Primary Care Provider: Other Provider: Medications: List any Medications you use Do you have any allergies to medications? If Yes, Explain: Surgical History List all major surgeries you have had Ocular History List any of the following you/family have had Crossed Eyes: Glaucoma: Self Family Self Family Lazy Eye- Amblyopia: Macular Degeneration: Self Family Self Family Drooping Eyelids: Detachment/Retinal Disease: Self Family Self Family Prominent/Protruding Eyes: Blindness: Self Family Self Family Eye Infection/Injury: Other: Self Family Cataracts: Self Family Self Family Ocular Medications List any ocular medications you use Ocular Surgical History List any ocular surgeries you have had Cataract Surgery Strabismus (Eye Turn) Social History List use of Tobacco, Alcohol, Narcotics & any STD's Tobacco Use: Alcohol Use: Narcotics: None None None Former Smoker Stopped Social Use Only Recreational months/years ago 1-2 Drinks Daily Chemical Dependence Light Smoker (<1 packs) Above Average Sexually Transmitted Disease: Moderate Smoker (1-2 packs) Alcohol Dependence None Heavy Smoker (>2 packs) Yes HIV Positive Signature: :

3 EyeZone, Inc. is committed to providing you with quality and affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have developed this payment policy. Please read it, ask any questions you may have, and sign in the space provided. A copy will be provided to you upon request. Insurance Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage. We participate in most medical and vision insurance. If you are not insured by a plan we are contracted with, payment in full is expected at each visit. If you are insured by a plan we are contracted with but don t have an up-to-date insurance card, payment in full for each visit is required. Co-Payments/Co-Insurance All co-payments must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments/co-insurance from patients can be considered fraud. Please help us in upholding the law by paying your co-payment/co-insurance at each visit. Non-covered services Please be aware that some or perhaps all of the services you receive may be non-covered or not considered reasonable or necessary by your insurance. You must pay for these services in full at the time of visit. Proof of insurance All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver s license and current valid insurance to provide proof of insurance. Claims submission We will submit your claims to assist you in getting your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays the claim. Change in Insurance Coverage It is the patient s responsibility to notify our office prior to their appointment of any and all changes to their insurance coverage. Nonpayment If your account is over 90 days past due, you will receive a letter stating that you have 15 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged as a patient. If this is to occur, you will be notified by mail Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know if you have any questions or concerns. I have read and understand the payment policy and agree to abide by its guidelines: Signature of patient or responsible party

4 I,, acknowledge that I have received a copy of EyeZone Nevada s HIPAA Notice of Privacy Practices. Patient Signature OR Signature of Personal Representative Authority of Personal Representative to Sign for Patient (check one): [ ] Parent [ ] Guardian [ ] Power of Attorney [ ] Other: **Please Note: It is your right to refuse to sign this Acknowledgement indicating that we have offered you a copy of our Notice of Privacy Practices. OFFICE USE ONLY I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: An emergency prevented us from obtaining acknowledgement. A communication barrier prevented us from obtaining acknowledgement. The individual was unwilling to sign. Other: (Please specify):

5 GENERAL EYEWEAR POLICIES ALL SPECTACLE SALES ARE FINAL EyeZone does not offer refunds for eyewear purchases. All spectacle sales are custom, and therefore, final. If a prescription change is noted within 90 days of the original order, our laboratory will remake the lenses with original lens options (such as anti-reflective coating, tints, etc.). Any difference in the original order price and final price is not refunded. There is no charge for a prescription check within 90 days; however, any recheck after 90 days will be subject to an office visit charge. If you elect to use your own frame and would like your old lenses returned from the laboratory, staff must be informed at time of order. If you do not inform staff of this request, the existing lenses will be disposed. DAMAGE Our frames are warranted for one year from the time of purchase unless otherwise specified. Our frame policy is a manufacturer-defect warranty. This does not cover lost or stolen frames, frames that have been sat or stepped on, or abused in any way. If your frame breaks, we will return all parts to the manufacturer, and the manufacturer will determine if it is a manufacturer s defect. If it is a manufacturer s defect, your frame will be covered at 100%. If the manufacturer determines that it is abuse, you will be responsible for replacing your frame or any broken parts. If your warranted lenses become scratched from normal wear-and-tear, they will be replaced at no-charge for up to 12 months from the date of purchase. If the lenses are scratched from abuse, you will be responsible for replacing them. Cause of lens scratches will be determined by the laboratory. They manufacture the lenses and are experts in lens defects. FRAME WAIVER I am aware that if I am using my own frame, I will not hold the doctors, office staff, laboratory, or any other optical company responsible for damage upon lens insertion or frame adjustment. CONTACT LENS FITTINGS AND RECHECKS As with spectacle prescription checks, there is no charge for a prescription check for contact lenses within 90 days of the initial contact lens evaluation. After that point, prescription checks are subject to an office visit charge. In the event that a contact lens evaluation is desired after the comprehensive examination has taken place, there will be a fee for the contact lens evaluation only within 90 days. Beyond 90 days, there will be a fee for both an office visit and contact lens evaluation. I have read and understand ALL of the above policies. Signature of Patient (or Guardian)

Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA Phone: Fax:

Figgs Eye Clinic and Optical / Wilson Contact Lens 1410 Lakeside Court #103 Yakima, WA 98902 Phone: 453-2010 Fax: 225-6421 Patient Name: Last: First: Middle Initial: Nickname: Sex: M / F Date of Birth: